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FOR OFFICE USE: _____________________________________________ _________ APPLICATION FOR SANITATION PERMIT Permit No. .--171_...J�..... --------------------- (Complete in Duplicate) Date Issued _______!/_1_ _ � _________________________________________________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. /2This application is made in compliance with County Ordin ce No. 549, 0&3 2s-U--Oy 1.3 2—EKI�� t r o J08 ADDRESS AN L CATIONhce.. --r1>�---•--- ------ -- . Owner's Name---- - -----------' --- - - -----•-••- - - -- ---------- ----- ----------- - one------.----•---------------------- Address------It --- -- ----------- - -- — ----------•--••-- -•- ----- - o � 1 •- ------------------------ Contractor's Name----- --•-.--------- --------- Phone-----•--_---------••-- -- -- - • -- •• --- -...e.-----•-•----------- •-•------- Installation will serve: Residence 1 Apartment House E] Commercial ❑ Trailer Court E] Motel C] Other ❑ Number of living units: __�[-_-_ Number of bedrooms __ Number baths __A Lot size _________________________________ _______________________ Water Supply: Public system E] Community system ❑ Private pfh +o Water Table -------- Character of soil to a depth of 3 feet: Sand E] Gravel E] ft.Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------------------ -) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) C � Septic ank: distance from nearest well----- --_.Distance/from foundation--------- Il'___..Ma01 t_erJal--- ------------------------- ------------ No. of compartments____ Size_� tfe- - Liquid depth____-___/xY_-. CapacitY__�Aa_ -------- - - Dispo Field: Distance from nearest well-- ___-_Distance from foundation.-- 490-_-------Distance to nearest lot line5� V __. i Number of lines_________a____ Length of each line---------/_Of)-------------Width of trench.----- ._-_----_____---___ ___ � i Type of filter material_________ _ ___________Depth of filter material--- length___-c�au-_______-____-_________- tk See pa Pit: Distance to nearest well____ f]-D.___-_---Distance from oundatio-________________.Distance to nearest lot line__--5�-__�. Number of pits_______-___--Lining material__ ------.Size: Diameter-------q-w;,-----Dept h_rr2—� ----- m Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____--____________-______________-___. ❑ Size: Diameter---------------------------------- ---Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------.-_---_. ❑ Distance to nearest lot line------------------------------------------------------------------•-•-•_•--------------------------------------------------------------------- Remodeling and/or repairing (describe)---------- ----------------------- -----------------------------•----------•---------•------------------------------------------------------------------- -----------------------------------------------------------•-------------------•----------------------------------------------------------------------------•--------------------------------•---------- l -- -----------------------•----------------------------•-----...---------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- -- ----- --<_- ---------------------------------------------------------------------{�Zd/or.Contractor) By: - ------------ (Tit le) (Plot plan, showing size of lot, location of syst m in rel t' n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -- -------------------------------------------------------- DATE-4 -------------------------- REVIEWEDBY--------------------------------------------------------------------------------- -------------------------------------------- DATE---•--------------•--------------------------------------- BUILDING PERMIT ISSUED_---------------------------------------------------------------------------- ------ DATE-------------------------------------------------------- ---- Alterations and/or recommendations:------------------------ - ------------------------------------------------------------------------------------------------------------------------------- -------•-----------•--------------------------------------------------------------------------------------------------•-•--------------•---------------------------------------M------------------------------------------•--- -------------------------------------------------------------------------------- ------------------••------------------------------------------------ -------------------------- ------ ---------------------- FINAL INSPECTION BY__ _ _ ___ _ _ -----------------------------------------�� ' Date-� ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 99 9 REVISED B-59 3M 3-'63 F.R.gD.